State of the Addiction Treatment Field: Where We Are and Where We Need to Go
State of the Addiction Treatment Field:
Where We Are and Where We Need to Go
by Tom Horvath, Ph.D., ABPP
The following article is based on the presentation I gave at the Evolution of Addiction Treatment Conference in Los Angeles, February 2-5, in a Keynote Panel Presentation entitled “State of the field address: Where we are and where we need to go.” I was one of seven presenters. We each had up to 15 minutes. The entire presentation lasted two hours, including a brief discussion period at the end. The two presenters before me were not proposing the radical changes I was, so I began by addressing the fact that my presentation was likely to be an outlier in this group.
I want to focus primarily on where we need to go. If you work from a disease model, 12-step, abstinence only framework, what I’m about to say may seem wrong. Completely wrong. Outrageously wrong.
Fortunately, most of what I’m proposing we do is already being done successfully, but typically in other countries. Further, many of these ideas also have significant scientific evidence to support then. Given that the US has one of the worst substance problems in the world, how other countries address this issue is worth considering.
There are four broad themes to my presentation: Decriminalization, harm reduction, multiple pathways to recovery, and support for families. It is not our role to lead change on all of these themes, such as decriminalization, but we can still advocate for them.
1) Decriminalization of drugs and drug use
Ideally in this country we would provide everyone with a good family, a good education, good economic opportunity, and a safe living environment. Under these conditions we would have few substance problems. However, no society has yet created utopia, so we need to be more pragmatic.
We could become like Portugal and other countries that have decriminalized substance use to varying degrees, most notably Switzerland, the Netherlands, and Australia. To remind you, decriminalization is not legalization. Under decriminalization the sale of large quantities of substances (which is to say, being a drug dealer) is still illegal. Individual use and possession is acceptable.
Although legalization is worth investigating, it may be a step too far for now. Legalization may be better ultimately, but it is as yet untested, except for alcohol (and increasingly, for marijuana).
We would still regulate substance use, as we do now with alcohol. We could probably do a better job of regulating alcohol than we do, and the regulation of other substances might be a good influence on alcohol regulations. The regulation of tobacco products also sets an example to follow, given that smoking in the US has fallen in 50 years from nearly 50% of the population to about 15%.
One very specific change would involve providing methadone at pharmacies, inexpensively, when prescribed by any physician. If you think that methadone cannot be used with relative safety, then remember that alcohol is often more dangerous than any opiate. Of course, high doses of a wide range of substances can be lethal, including high doses of oxygen or water.
We might also someday have all substances available at pharmacies, as they were before the Harrison Narcotics Act of 1914. Physicians could prescribe them and monitor patient safety, just as they do now when they prescribe opiates for pain or stimulants for ADD and other disorders.
If you want to investigate how substance decriminalization works in practice see Johann Hari’s TED talk, now with over 6 million views, or his book, Chasing the Scream. If you think allowing these substances to be available is a horrible idea, you might be interested in investigating the lives of well-known individuals who used opiates regularly, including Coco Channel, Senator Joe McCarthy, Dr. William Halstead, and Charles Dickens. As their lives show, the primary problems for most opiate users do not arise from opiate use, but from how opiate users are treated.
My focus on decriminalization should not be construed as my recommending substance use. Rather, I am accepting the reality that we will never have a substance free society. As a cognitive behavioral therapist I rarely use the term “never,” but I believe in this instance the term is used accurately.
2) Harm reduction as the overarching orientation of our treatment and recovery system
In the Surgeon General’s recently released report, Facing Addiction in America, he states:
Treatment engagement and harm reduction interventions, for individuals who have a substance use disorder but who may not be ready to enter treatment, help engage individuals in treatment and reduce the risks and harms associated with substance misuse. (p. 4-4)
Harm reduction programs provide public health-oriented, evidence-based, and cost-effective services to prevent and reduce substance use-related risks among those actively using substances, and substantial evidence supports their effectiveness. (p. 4-10)
If “harm reduction” is not in your professional vocabulary, it is time to start using it.
If we adopt harm reduction as an over-arching perspective on recovery, we would start promulgating public health messages such as these:
- Mixing drugs, especially opiates with benzos or other downers, can be lethal
- Most people resolve problematic addictive behavior on their own; you don’t need to wait for treatment
- Many different kinds of support are available for overcoming problematic addictive behavior, including treatment
- Is your loved one not ready to change? Help them see a better life for themselves using the Community Reinforcement and Family Training approach
We would also stop emphasizing addiction as a disease, although people would be supported in that belief if they have it. We would aim toward a society with few people at the ends of the substance use spectrum. Rather than many abstainers and many lives lost to addiction, most of us would use one or more substances moderately, as we already have with caffeine and alcohol, and nicotine when it is separated from tobacco.
What about the treatment industry? We do not need to eliminate anything we have in place at present. The one change many addiction providers would need to make is to function as a specialist or generalist.
A specialist could say: “I am a specialist. This is the kind of treatment I provide. If you are interested in participating in it, then we can begin immediately. However, if you want a comprehensive evaluation and a discussion of all your treatment and recovery options, then you need to see a generalist.”
There is nothing wrong with someone specializing in 12-step, disease model, abstinence only treatment. However, prospective clients need unbiased and accurate information about the full range of treatment options. A generalist would have at least a Masters degree and a mental health license, in order to be suited to assessing comorbid conditions, which are often present.
Another reason to make the Masters degree and a license the minimum requirement for work in addiction treatment, as it is in mental health, is that truly effective addiction treatment is personalized, and not based on delivering a “program” to someone. As the Surgeon General also states:
Most evidence-based behavioral therapies are often implemented with limited fidelity and are under-used. (p. 4-2)
Despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems. (p. 4-26)
High quality addiction treatment is delivered one-to-one, in a completely personalized manner, and not delivered in educational groups teaching a program or curriculum. This treatment focuses primarily on comorbid and related issues, not on the addictive behavior alone. Drug and alcohol counselors who do not wish to rise to the standard of a Masters degree and license can probably apply their skills in what I hope will be a burgeoning system of recovery support services.
3) Multiple pathways to recovery from addiction
To give an example of how our field may acknowledge in a general way the need for multiple pathways, but then not follow through on specifics, let’s begin with a quote from AA’s Big Book, starting at the bottom of page 20, in a discussion about types of drinkers:
Then we have a certain type of hard drinker. He may have the habit badly enough to gradually impair him physically and mentally. It may cause him to die a few years before his time. If a sufficiently strong reason – ill health, falling in love, change of environment, or the warning of a doctor – becomes operative, this man can also stop or moderate, although he may find it difficult and troublesome and may even need medical attention.
If concluded someone was “a hard drinker,” would you know how to provide moderation training, or know where to refer the individual, and do so in a non-judgmental fashion? Would you resist the temptation to announce that this individual as actually an alcoholic, even if you knew her or his problems would not that severe? In short, do you truly support multiple pathways to recovery? The addiction generalists of the future will need to be fluent in a range of treatment and recovery options, including moderation training for alcohol problems, an approach that has been about as highly studied as any single treatment approach.
Another pathway that gets less attention than it merits is the self-empowering approach, as exemplified by the mutual help group SMART Recovery, and the CBT and motivational interviewing approaches that SMART is based on. If you are insisting the client endorse a disease perspective or commit to abstinence, you are not actually practicing CBT or MI.
Ultimately a well-organized system of pathways to recovery would be rooted in a national health system, not the hodge-podge of overlapping systems that has arisen because of having multiple health insurers. With a true system we could eliminate much of the admin cost we have now, most of the marketing costs, and focus on developing needed services. Undoubtedly a small, expensive, private sector would still exist, but few of us would work in it. Consistent with my emphasis on the countries that have decriminalized substance use, almost all high functioning nations have some version of national healthcare.
A great new example of a different pathway is the recently opened High Sobriety, a cannabis inclusive treatment center in Los Angeles. In this approach cannabis is viewed as an exit drug rather than a gateway drug. For many years I have seen case after case where that approach works. Joe Schrank, High Sobriety’s founder, is here today. I encourage you to talk with him. In line with this general idea, I can imagine specialized facilities that include some substances but not others. We already typically allow caffeine, nicotine, buprenorphine, methadone and now cannabis. It is not a stretch to imagine other options.
I suggest that the single most important fact about recovery is the willingness of the client. If we can create treatment approaches and facilities that diminish the “treatment gap,” which is the gap between the number of individuals who have diagnosable problems and the small percentage (about 10%) who seek treatment, we would be improving what we do. We can diminish the treatment gap by doing more than paying lip service to multiple pathways.
4) More support for families
Although non-confrontational “interventions” (such as the ARISE model) have a role to play, most families might be better served by CRAFT (Community Reinforcement And Family Training), developed and scientifically studied by Robert Meyers, Ph.D. Concerned Significant Others (CSO’s) attend 6-12 CRAFT sessions and learn how to change their own reactions to the Identified Patient (IP). The IP’s new intimate social environment facilitates change. CRAFT does not assume that CSO’s are responsible for the IP’s addictive problems. However, if CSO’s are willing to learn CRAFT skills, they can contribute in a powerful way to change in the IP. In scientific studies of CRAFT it is up to two to three times as effective as interventions or Al-Anon in getting the IP to enter treatment.
If CRAFT were available for free to any family member, we would see a dramatic impact on treatment seeking. Furthermore, even when the IP does not enter treatment, there is typically a substantial reduction in addictive problems.
Families can also be supported by better classes in schools about emotional and behavioral self-management. These classes could cover how to manage desires and cravings, how to regulate emotions, how to get along with others, how to accept yourself as you are (while still changing undesirable behaviors), and related topics. Addictive behavior would be viewed as simply an aspect of being human. As humans we all face the challenge of coping with desires and cravings. Managing addictive behavior is a problem for everyone. It is a problem that unites us, not one that divides us (into “addicts and alcoholics” in one group and “normies” in the other). Presumably children would come home and discuss what they learned at school, and Parent Teacher Associations might present overviews of these classes to parents, so that parents could reinforce the concepts at home.
It is unlikely that we will ever make our environment “safe” with respect to substances. We need to raise the average level of self-control, which is the capacity to honor long-term satisfactions even though short-term satisfactions have our attention. Classes on emotional and behavioral self-management, based on established scientific knowledge about these issues, could contribute to increased self-control.
In conclusion, I know that some of what I’ve said may seem wrong or dangerous. Thanks for listening. Later I’d be happy to converse with you. However, if you want to lecture someone, feel free to talk to the people who invited me!